CITY OF JEFFERSON

INVITATION FOR BIDS

Bid No.: IFB4353

Subject: Removal of Yard Waste from the City’s Yard Waste Collection Facility, 708 Ellis Boulevard.

Closing Date: Bids must be received no later than 1:30 p.m. on December 30, 2025. Bids should be submitted electronically through Bonfire. Hard-copy bids will also be accepted at the following address with the bid number and subject indicated on the envelope:

Office of the Purchasing Agent City of Jefferson 320 E McCarty St Jefferson City, MO 65101

Pre-Bid Conference: Pre-bid conference will NOT be held. All questions must be directed at the Purchasing

Agent.

Purchasing Agent: Megan Stephenson MStephenson@jeffersoncitymo.gov 573-634-6324 mailto:MStephenson@jeffersoncitymo.gov

REQUEST FOR BIDS

Removal of Yard Waste

Invitation

The City of Jefferson, Public Works, herein referred to as City, invites interested, qualified individuals or firms, herein referred to as bidders, contractor, etc., capable of providing services and supplies to remove and dispose of yard waste at the City’s yard waste collection site at 708 Ellis Boulevard. The submittal must satisfy all criteria established in this solicitation to qualify for an award, unless it is waived by the City as an informality, technicality, or irregularity, at the City’s sole discretion.

Information and Instructions to Bidders

Notice to Bidders

Before submitting the bid, each bidder shall become fully informed as to the extent and character of the work required.

No consideration will be granted for any alleged misunderstanding of the equipment to be used or services to be required, it being understood that the submission of a bid is an agreement to all items and conditions referred to herein.

Pre-bid Conference/Questions

A pre-bid conference will NOT be held. All questions regarding the bid specifications or process must be directed to Megan Stephenson, mstephenson@jeffersoncitymo.gov, 573-634-6324. All questions should be submitted no later than October 24, 2025. Bidders are encouraged to inspect the site on their own.

Bid Submittal

Bids must include the following:

• Method of Performance (Attachment B) – description of how the bidder intends to provide the services, equipment available, etc.

• References(Attachment C)– List of customers of a comparable size and requirements as specified herein. The City reserves the right to contact the references identified, as well as any other customers not identified.

• Subcontractors – Bidders shall submit the names and role of all principal subcontractors, if any, with the proposal.

• Pricing Form (Attachment A) – Proposers shall state firm, fixed pricing to complete the work.

mailto:mstephenson@jeffersoncitymo.gov

• E-Verify Affidavit and copy of the signature page of the MOU between the bidder and Homeland Security (Attachment D)

Bids should be submitted electronically through Bonfire, the City’s free electronic procurement system: https://jeffersoncitymo.bonfirehub.com.

Bids may also be submitted hard copy with the bid number (IFB4353) indicated on the outside of the envelope and must be submitted to the following address:

City of Jefferson Purchasing Agent 320 E McCarty Street Jefferson City, MO 65101

Bids must be received no later than 1:30 p.m. on December 30, 2025.

Bids will be publicly opened at 1:30 p.m. on December 30, 2025.

Subcontractors

The Contractor shall be responsible to the City for acts, defaults and omissions of their Subcontractors of any tier.

The Subcontractors of any tier shall be bound by the applicable terms and provisions of the contract, but no contractual relationship shall exist between subcontractors of any tier and the City.

Bidders shall list all and any subcontractors they intend on using.

Evaluation and Award

Award will be made to the lowest bidder whose bid conforms to the solicitation that will be most advantageous to the City.

Delivery and Storage

Contractor is responsible for delivery and storage of all equipment and supplies required for this project. All bids must be bid with shipping to be FOB destination.

Withdrawal of Bids

Bidders may withdraw their bid after depositing them with the Purchasing Agent at any time prior to the stipulated time for opening such bids. No bid may be withdrawn within thirty (30) days after the opening thereof, unless obvious errors are apparent.

https://jeffersoncitymo.bonfirehub.com/

Right to Accept or Reject Bids

The right is hereby reserved to accept or reject all or part of any bid, to waive informalities and to request new bids as the interest of the City may require.

Tax Exempt Status

The City of Jefferson is tax exempt by law. Do not include tax in bidding. A federal tax-exempt certificate will be furnished when requested.

Contract with Third Parties

The bidder shall not enter into any contractual agreement with a third party for the performance of any conditions under this bid without the express written approval of the City.

Invoicing and Payment

The contractor shall submit invoices for services to the City of Jefferson, Public Works, 320 E.

McCarty Street, Jefferson City, Missouri 65101. The City shall only be liable for charges as indicated on the Pricing Form.

Restrictive Clause

Bidders must contact the Office of the Purchasing Agent at least five (5) days prior to the bid opening if any of the specification contains restrictive language or requirements that render him unable to bid.

Americans with Disabilities Act

Individuals should contact the ADA Coordinator at (573) 634-6570 to request accommodations or alternative formats as required under the Americans with Disabilities Act. Please allow three (3) business days to process the request.

Federal Work Authorization Program

Bidders that meet the definition of a business entity as defined in section 285.525, RSMo, pertaining to section 285.530, RSMo, providing services exceeding $5,000, shall maintain enrollment and participation in a federal work authorization program with respect to the employees hired after enrollment in the program who are proposed to work in connection with the contracted services included herein. If the contractor’s business status changes during the life of the contract to become a business entity as defined in section 285.525, RSMo, pertaining to section 285.530, RSMo, then the contractor shall, prior to the performance of any services as a business entity under the contract enroll and participate in a federal work authorization program, such as E-Verify.

Bidders must, by sworn affidavit and provision of documentation (copy of E-Verify Memo of Understanding Electronic Signature Page), affirm their enrollment and participation in a federal work authorization program. Bidders shall complete and sign the Affidavit of Compliance with Section 285.525-285.550 RSMo and submit a copy of the signature page of their MOU with Homeland Security. See Affidavit of Compliance with E-Verify document (Attachment B).

Non-Discrimination Statement

The City does not discriminate on the basis of race, color, national origin, or gender in the award and performance of any contract.

Work Limitations

Care must be exercised at all times to maintain safe clearance and safe working practices, both for equipment and personnel, in order to avoid injury or service interruption. All job personnel must be made thoroughly acquainted with the hazards involved. It shall be the contractor’s responsibility to make this condition clear to all contractors’ personnel.

Contract Period

Contract period shall be from the date of contract for the number of days indicated on the Pricing Form. A contract will be sent to the recommended bidder. Once the contract is received, the City would like the contract signed and returned back to the City as soon as possible. It is desired that the intended contractor returns the contract within three days of receipt unless other arrangements are made with the City.

Indemnification and Insurance Requirements/Contract

The contractor agrees to indemnify and hold harmless the City from all claims and suits for loss of or damage to property, including loss of all judgments recovered therefore, and from all expense in defending said claims, or suites, including court costs, attorney fees and other expense caused by any act or omission of the contractor and/or his subcontractors, their respective agents, servants or employees.

The contractor shall obtain and maintain throughout the term of the contract all insurance as specified in the sample contract. See Exhibit 1 – Sample Contract.

Upon acceptance of bid, the contractor shall enter into a contract for this work as outlined by the City. See Exhibit 1 – Sample Contract.

Changes to Bid Documents

Changes to solicitation documents prior to bidding will be by addendum issued by the City. Bidders shall acknowledge receipt of all addenda on bid forms.

Termination

The City reserves the right to terminate the contract at any time, for the convenience of the City, without penalty or recourse, by giving written notice to the contractor at least thirty (30) calendar days prior to the effective date of such termination. The contractor shall be entitled to receive compensation for services and/or supplies delivered to and accepted by the City pursuant to the contract prior to the effective date of termination.

Laws and Regulations

The contractor shall perform services in accordance with all applicable state, local and federal statutes and legal requirements in his performance of this contract. In addition, the bidder’s attention is directed to City Code, Chapter 17 – Licenses, Taxation and Miscellaneous Business Regulation.

Before an award of contract or purchase order can be made, bidders doing any service or business within the corporate city limits of the City of Jefferson must have a current business license and be registered with the Secretary of State’s Office.

Proprietary Products

Any piece of equipment described herein that is a proprietary product, or the use of a manufacturer or vendor’s brand name, is referenced with the intent to indicate a standard of design desired by the buyer and shall not be construed to exclude other manufacturer’s products of comparable quality. The buyer reserves the right to determine the quality of the equipment offered.

Preference for U.S. Manufactured Goods

On purchases more than $25,000, the city shall select products manufactured, assembled or produced in the United States, if quantity, quality, and price are equal. Every contract for public works construction or maintenance more than $25,000 shall contain a provision requesting the contractor to use American products in the performance of the contract.

SCOPE OF WORK

General Information

The Public Works Department (City) seeks to contract with a firm or individual to remove yard waste from the City’s yard waste collection facility at 708 Ellis Boulevard. This is a one-time removal.

The City surveyed the yard waste pile on 12/10/2025. The results stated that there were approximately 3000 cubic yards of material. This material has been stored and driven over by a tracked high lift. It is compacted. Yard waste received since that date is in a segregated pile.

Requirements

1. Contractor shall provide all supervision, labor, tools, equipment, materials, and supplies necessary to remove yard waste. Vendor may need the following equipment: stump grinders, horizontal grinder, woodchippers, excavators, long- reach track hoe, etc.

2. Contractor shall remove the yard waste from the facility and place/dispose of the yard waste in a manner consistent with Missouri’s Solid Waste Management Law and Regulations.

3. Contractor must work with the City to gain access to the site.

4. Contractor shall provide a single point of contact for the City.

5. Contractor shall have considerable experience.

6. Contractor shall be solely responsible for pedestrian and vehicular safety and control within the worksite and shall provide the necessary warning devices, barricades, and ground personnel needed to give safety, protection, and warning to persons and vehicular traffic within the area.

Traffic control is the responsibility of the contractor and shall be accomplished in conformance with state, county, and local highway construction codes. Contractor shall take steps to ensure the site is accessible to the public if the facility opens during removal operations.

The site may be open to the public during normal operating hours.

7. Work shall proceed continuously until complete. All work shall be completed within two (2) weeks once the Notice to Proceed is given.

8. Contractor shall schedule work between 7:00 a.m. and 6:00 p.m. Monday through Friday unless authorized by the City to do otherwise.

EXHIBIT 1 – SAMPLE CONTRACT

CITY OF JEFFERSON

CONTRACT FOR PROFESSIONAL SERVICES

THIS CONTRACT, made and entered into the date last executed by a party as indicated below, by and between the City of Jefferson, a municipal corporation of the State of Missouri, hereinafter referred to as “City”, and the __________________, hereinafter referred to as “Contractor”.

WITNESSETH:

THAT WHEREAS, the City desires to engage the Contractor to render certain services for the removal of yard waste at 708 Ellis Blvd, Jefferson City, MO, hereinafter described in Exhibit A.

WHEREAS, Contractor has made certain representations and statements to the City with respect to the provision of such services and the City has accepted said proposal to enter into a contract with the Contractor for the performance of services by the Contractor.

NOW THEREFORE, for the considerations herein expressed, it is agreed by and between the City and the Contractor as follows:

1. Scope of Services.

Contractor agrees to provide all supervision, labor, tools, equipment, materials and supplies for the removal of yard waste at 708 Ellis Blvd, as set forth in Exhibit A. In the event of a conflict between this agreement and any attached exhibits, the provisions of this agreement shall govern and prevail.

2. Payment.

The City hereby agrees to pay Contractor for the work done pursuant to this contract according to the payment schedule set forth in the contract documents upon acceptance of said work by an Agent of the City of Jefferson’s Public Works Department, and in accordance with the rates and/or amounts stated in the bid of Contractor dated ___________, which are by reference made a part hereof. No partial payment to Contractor shall operate as approval or acceptance of work done or materials furnished hereunder. No change in compensation shall be made unless there is a substantial and significant difference between the work originally contemplated by this agreement and the work actually required. The total amount for services rendered under this contract shall not exceed __________ Dollars ($_______).

3. Term.

This contract shall commence on the date last executed by a party as indicated below. The Contractor shall complete said work, as set forth in Exhibit A, by ___________________.

4. Additional Services.

The City may add to Contractor services or delete therefrom activities of a similar nature to those set forth in Exhibit A, provided that the total cost of such work does not exceed the total cost allowance as specified in paragraph 2 hereof. The Contractor shall undertake such changed activities only upon the direction of the City.

All such directives and changes shall be in written form and approved by the City and shall be accepted and countersigned by the Contractor or its agreed representatives.

5. Personnel to be Provided.

The Contractor represents that Contractor has or will secure at its expense all personnel required to perform the services called for under this contract by the Contractor. Such personnel shall not be employees of or have any contractual relationship with the City except as employees of the Contractor. All of the services required hereunder will be performed by the Contractor or under the Contractor’s direct supervision and all personnel engaged in the work shall be fully qualified and shall be authorized under state and local law to perform such services. None of the work or services covered by this contract shall be subcontracted except as provided in Exhibit A without the written approval of the City.

6. Contractor’s Responsibility for Subcontractors.

It is further agreed that Contractor shall be as fully responsible to the City for the acts and omissions of its subcontractors, and of persons either directly or indirectly employed by them, as Contractor is for the acts and omissions of persons it directly employs. Contractor shall cause appropriate provisions to be inserted in all subcontracts relating to this work, to bind all subcontractors to Contractor by all the terms herein set forth, insofar as applicable to the work of subcontractors and to give Contractor the same power regarding termination of any subcontract as the City may exercise over Contractor under any provisions of this contract.

Nothing contained in this contract shall create any contractual relations between any subcontractor and the City or between any subcontractors.

7. Independent Contractor.

The Contractor is an independent contractor and nothing herein shall constitute or designate the Contractor or any of its employees as agents or employees of the City.

8. Benefits not Available.

The Contractor shall not be entitled to any of the benefits established for the employees of the City and shall not be covered by the Workmen’s Compensation Program of the City.

9. Nondiscrimination.

The Contractor agrees in the performance of the contract not to discriminate on the grounds or because of race, creed, color, national origin or ancestry, sex, religion, handicap, age or political affiliation, against any employee of Contractor or applicant for employment and shall include a similar provision in all subcontracts let or awarded hereunder.

10. Illegal Immigration.

Prior to commencement of the work:

a. Contractor shall, by sworn affidavit and provision of documentation, affirm its enrollment and participation in a federal work authorization program with respect to the employees working in connection with the contracted services.

b. Contractor shall sign an affidavit affirming that it does not knowingly employ any person who is an unauthorized alien in connection with the contracted services.

c. If Contractor is a sole proprietorship, partnership, or limited partnership, Contractor shall provide proof of citizenship or lawful presence of the owner.

11. Notice to Proceed.

The services of the Contractor shall commence upon execution of this Agreement, and shall be undertaken and completed in accordance with the schedule contained in Exhibit A.

12. Termination.

If, through any cause, the Contractor shall fail to fulfill in timely and proper manner its obligations under this contract, or if the Contractor shall violate any of the covenants, agreements, or stipulations of this contract, the City shall thereupon have the right to terminate this contract by giving written notice to the Contractor of such termination and specifying the effective date thereof, at least five (5) days before the effective day of such termination. The City reserves the right to terminate this contract for convenience by giving at least fourteen

(14) days prior written notice to Contractor, without prejudice to any other rights or remedies of the City, provide Contractor shall be entitled to payment for all work completed by Contractor through the date of termination. The Contractor may with cause terminate this contract upon 30 days prior written notice. In either such event all finished or unfinished documents, data, studies, surveys, drawings, maps, models, photographs, and reports or other materials prepared by the Contractor under this contract shall, at the option of the City, become its property, and the compensation for any satisfactory work completed on such documents and other materials shall be determined. Notwithstanding the above, the Contractor shall not be relieved of liability to the City for damages sustained by the City by virtue of any such breach of contract by the Contractor.

13. Waiver of Breach.

Failure to insist upon strict compliance with any of the terms covenants or conditions herein shall not be deemed a waiver of any such terms, covenants or conditions, nor shall any failure at one or more times be deemed a waiver or relinquishment at any other time or times by any right under the terms, covenants or conditions herein.

14. Authorship and Enforcement.

Parties agree that the production of this document was the joint effort of both parties and that the contract should not be construed as having been drafted by either party. In the event that the City successfully enforces the terms of this contract through litigation, the City shall be entitled to receive, in addition to any other relief, its reasonable attorney’s fees, expenses and costs.

15. Severability.

If any section, subsection, sentence, or clause of this contract shall be adjudged illegal, invalid, or unenforceable, such illegality, invalidity, or unenforceability shall not affect the legality, validity, or enforceability of the contract as a whole, or of any section, subsection, sentence, clause, or attachment not so adjudged.

16. Assignment.

The Contractor shall not assign any interest in this contract, and shall not transfer any interest in the same (whether by assignment or novation), without prior written consent of the City thereto. Any such assignment is expressly subject to all rights and remedies of the City under this agreement, including the right to change or delete activities from the contract or to terminate the same as provided herein, and no such assignment shall require the City to give any notice to any such assignee of any actions which the City may take under this agreement, though City will attempt to so notify any such assignee.

17. Existing Data.

All information, data and reports as are existing, available and necessary for the carrying out of the work, shall be furnished to the Contractor without charge by the City, and the City shall cooperate with the Contractor in every reasonable way in carrying out the scope of services. The Contractor shall not be liable for the accuracy of the information furnished by the City.

18. Confidentiality.

Any reports, data or similar information given to or prepared or assembled by the Contractor under this contract which the City requests to be kept as confidential shall not be made available to any individual or organization by the Contractor without prior written approval of the City.

19. Indemnity.

To the fullest extent permitted by law, the Contractor will defend, indemnify and hold harmless the City, its elected and appointed officials, employees, and agents from and against any and all claims, damages, losses, and expenses including attorneys’ fees arising out of or resulting from the performance of the work, provided that any such claim, damage, loss or expense (1) is attributable to bodily injury, sickness, disease, or death, or to injury to or destruction of tangible property (other than the work itself) including the loss of use resulting therefrom and (2) is caused in whole or in part by any negligent act or omission of contractor, any subcontractor, anyone directly or indirectly employed by any of them or anyone for whose acts any of them may be liable, regardless of whether or not it is caused in part by a party indemnified hereunder. Such obligation shall not be construed to negate, abridge, or otherwise reduce any other right or obligation of indemnity which would otherwise exist as to any party or person described in this paragraph.

20. Insurance.

Contractor shall provide, at its sole expense, and maintain during the term of this agreement commercial general liability insurance with a reputable, qualified, and financially sound company licensed to do business in the State of Missouri, and unless otherwise approved by the City, with a rating by Best of not less than “A,” that shall protect the Contractor, the City, and the City’s officials, officers, and employees from claims which may arise from operations under this agreement, whether such operations are by the Contractor, its officers, directors, employees and agents, or any subcontractors of Contractor. This liability insurance shall include, but shall not be limited to, protection against claims arising from bodily and personal injury and damage to property, resulting from all Contractor operations, products, services or use of automobiles, or construction equipment at a limit of $500,000 Each Occurrence, $3,500,000 Annual Aggregate; provided that nothing herein shall be deemed a waiver of the City’s sovereign immunity. An endorsement shall be provided which states that the City is named as an additional insured and stating that the policy shall not be cancelled or materially modified so as to be out of compliance with the requirements of this section, or not renewed without 30 days advance written notice of such event being given to the City.

21. Documents.

Reproducible copies of tracings and maps prepared or obtained under the terms of this contract shall be delivered upon request to and become the property of the City upon termination or completion of work. Copies of basic survey notes and sketches, charts, computations and other data prepared or obtained under this contract shall be made available, upon request, to the City without restrictions or limitations on their use.

When such copies are requested, the City agrees to pay the Contractor its costs of copying and delivering same.

22. Books and Records.

The Contractor and all subcontractors shall maintain all books, documents, papers, accounting records and other evidence pertaining to costs incurred in connection with this contract, and shall make such materials available at their respective offices at all reasonable times during the contract and for a period of three (3) years following completion of the contract.

23. Nonsolicitation.

The Contractor warrants that they have not employed or retained any company or person, other than a bona fide employee working solely for the Contractor, to solicit or secure this contract, and that they have not paid or agreed to pay any company or person, other than a bona fide employee working solely for the Contractor, any fee, commission, percentage, brokerage fee, gifts, or any other consideration, contingent upon or resulting from the award or making of this contract. For breach or violation of this warranty, the City shall have the right to annul this contract without liability, or, in its discretion, to deduct from the contract price or consideration, or otherwise recover the full amount of such fee, commission, percentage, brokerage fee, gifts, or contingent fee.

24. Delays.

That the Contractor shall not be liable for delays resulting from causes beyond the reasonable control of the Contractor; that the Contractor has made no warranties, expressed or implied, which are not expressly set forth in this contract; and that under no circumstances will the Contractor be liable for indirect or consequential damages.

25. Amendments.

This contract may not be modified, changed or altered by any oral promise or statement by whosoever made;

nor shall any modification of it be binding upon the City until such written modification shall have been approved in writing by an authorized officer of the City. Contractor acknowledges that the City may not be responsible for paying for changes or modifications that were not properly authorized.

26. Governing Law.

The contract shall be governed by the laws of the State of Missouri. The courts of the State of Missouri shall have jurisdiction over any dispute which arises under this contract, and each of the parties shall submit and hereby consents to such courts exercise of jurisdiction. In any successful action by the City to enforce this contract, the City shall be entitled to recover its attorney’s fees and expenses incurred in such action.

27. Notices.

All notices required or permitted hereinunder and required to be in writing may be given by first class mail addressed to the following addresses. The date and delivery of any notice shall be the date falling on the second full day after the day of its mailing.

If to the City: If to the Contractor:

City of Jefferson Name Department of Law Attn:

320 East McCarty Street Address Jefferson City, Missouri, 65101 Address

(Signatures on next page)

CITY OF JEFFERSON, MISSOURI CONTRACTOR

City Administrator Title:

Date: __________ Date: __________

ATTEST:

Title:

APPROVED AS TO FORM:

City Attorney

ATTACHMENT A – PRICING FORM

(Only use this form if submitting a hard-copy bid)

Item Number Description Unit of Measure Pricing

1. Removal of Yard Waste Lump Sum

TOTAL

Discount for prompt payment on invoices only ___%___ days. Discount will not be evaluated on bid.

The prices contained in this bid are firm for _____ days prior to award.

SUBCONTRACTORS

All subcontractors shall be listed if the bidding intends to use subcontractors.

I/We the undersigned do hereby certify that the information presented in this proposal is true and accurate and agree to provide the specified products and services at the price and time stated if awarded the bid. I/We also certify that I am a duly authorized representative of the business entity below and that I possess the legal authority to sign on behalf of the business for which I am acting.

Name of Company

Agent & Title

Address

Telephone

Email Address

Signature & Date

Form of Business: __ Sole Proprietorship __ Partnership __Corporation __ Limited Liability Corporation

ATTACHMENT B – METHOD OF PERFORMANCE

Offeror may use this form, or any format desired, to present a written plan for performing the requirements specified in the request.

ATTACHMENT C - REFERENCES

Name of Firm ________________________________ Address ____________________________________

Contact Person __________________________________ Telephone No. ________________________

Date of Services _________________________ Number of Personnel _________________________

Description of Services: ___________________________________________________________________

Project Responsibilities: ___________________________________________________________________

Date of Services _________________________ Number of Personnel _________________________

Description of Services: ___________________________________________________________________

Date of Services _________________________ Number of Personnel _________________________

Description of Services: ___________________________________________________________________

Date of Services _________________________ Number of Personnel _________________________

Description of Services: ___________________________________________________________________

ATTACHMENT D

Affidavit of Compliance with Section 285.525-285.550 RSMo

For All Services in Excess of $5,000.00

State of ________________________ ) ) ss County of ______________________ )

I, __________________________, am an authorized agent of _________________________ (Bidder). This business is enrolled and participates in a federal work authorization program for all employees working in connection with services provided to the City of Jefferson. This business does not knowingly employ any person that is an unauthorized alien in connection with the services being provided. Documentation of participation in a federal work authorization program (signature page of the MOU with Homeland Security) is attached to this affidavit.

Furthermore, all subcontractors working on this contract shall affirmatively state in writing in their contracts that they are not in violation of Section 285.530.1 RSMo, shall not thereafter be in violation and submit a sworn affidavit under penalty of perjury that all employees are lawfully present in the United States.

Affiant Date

Subscribed and sworn to before me this _______ day of ___________, ______.

Notary Public

My commission expires: ___________________

If bidder is an individual and does not have any employees of any sort, complete this section.

I, the undersigned, being at least eighteen years of age, swear upon my oath that I am either a United States citizen or am classified by the United States government as being lawfully admitted for permanent residence.

Date Signature

Subscribed and sworn to before me this _______ day of ___________, ______.

Notary Public My commission expires: ___________________

Sample E-Verify Memo of Understanding – MOU Electronic Signature Page

Company ID Number: XXXXXXX

Approved by:

Employer Your Company Name Name (Please Type or Print) John Doe

Title

Signature

Electronically Signed

Date

05/27/2019

Department of Homeland Security – Verification Division

Name (Please Type or Print) USCIS Verification Division

Title

Signature

Electronically Signed

Date

05/27/2019